The following is a shortened edited version of the Presidential Address which I gave at the 2014 Annual Meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry held in New York May 2014. This article in edited form will also appear in the next issue of the The Forum, a magazine published by the American Academy of Psychoanalysis and Dynamic Psychiatry , Any comments are welcome at the end of this article
The American Academy of Psychoanalysis and Dynamic Psychiatry 75 Years From Today
Michae Blumenfield, M.D.
The theme of this meeting has been 75 Years After Freud and my talk in closing this meeting is the Academy 75 Years from today
Now let us look 75 years into the future – The year is 2089. I have a fantasy that the President of our organization will be my grandson Obi, who recently turned 5 years old now but at that time he will be 80 years old….. in the PRIME OF HIS LIFE. Obi’s life expectancy is to be 79-86 by projections today but many believe with scientific advances that we will have, it will be much longer. In fact, in an article in the Journal of Anti Aging Medicine a few years ago, 60 gerontologists from leading universities all over the world were asked for estimates regarding the development of future life expectancy for a person born in the year 2100 – 86 years from now. The median prediction was 100 years whereas the mean was 292- since 3 people predicted over 1000 years. – showing that there were some Death deniers.
I am doing a project where I am recording an audio interview with the past Presidents of the Academy and I had the pleasure of doing interviews with Milt Zaproloupus and Mary Ann Eckhardt both over 100 year old and going strong
So perhaps 80 year old Obi in his prime will be President of the Academy and he will be standing here or perhaps he will be speaking to us via Hologram .
One of my son’s is a TV producer and he said to me why don’t you do a live demonstration and project yourself into the lecture hall. I looked into this technology which is definitely available but now costs $100,000 so I thought I would save the Academy some money and let’s wait until the cost comes down. Holographs or not – In 75 years from now our President will be here surrounded by large screens where perhaps simultaneous gatherings will be taking place all over the world in lecture halls or in their offices watching and participating in this meeting
I believe it is fair to say that we will be an international organization. This year during my presidency we changed the international dues schedule based on World Bank calculations so our international colleagues can afford to join. Those of you teaching in the CAPA (Chinese American Psychoanalytic Alliance) know about the nascent but growing interest in psychodynamics in China which will be full grown in 75 years. In fact I predict before 75 years we will change our name from the American Academy of Psychoanalysis and Dynamic psychiatric to just the Academy of Psychoanalysis & Dynamic Psychiatry. I believe we will still be aligned with the APA and American Psychiatry …but if we follow the trends of international psychiatry so we can also be aligned with international psychiatrists who value psychodynamic psychiatry.
We are in the midst of a technology revolution that clearly affects the way we communicate with each other. Many of us are doing therapy using Skype or newer technology. I am treating a Chinese psychiatrist in China via this video technology 2x/week as part of the CAPA program Chinese American Psychoanalytic Alliance. I have treated college students who when they left to go to out of town college continued seeing me via Skype . Many of you are doing similar things
In 75 years from now we will also be teaching psychodynamic psychiatry via the latest technology. Many of you are already teaching and supervising via Skype or similar technology. I have had the exciting experience of teaching a class by SKYPE in psychoanalytic technique to Chinese students simultaneously in three different cities in China for CAPA
My colleague Jim Strain and I have set up a program where we have offered long distance courses to 3rd world countries and have taught psychosomatic medicine via Skype or similar technology in Colombia South American and Rwanda.
It is also interesting to consider what role will the Academy play in providing teaching courses in psychoanalytic and psychodynamic theory and treatment in the United States. While at present this is being provided by the residency programs and psychoanalytic Institutes, there are many changes going on now in the systems of post graduate education. It may very well be that in future years the Academy will take a very important role in providing the latest teaching of psychodynamic psychiatry and will do much of it using the latest techniques delivering classes and perhaps supervision directly.
After I prepared this talk, I opened the NY Times and I learned that 3D Virtual Reality will be here very shortly. Facebook has paid 2 Billion dollars for a Virtual Reality Company that will give people the illusion that they are physically present in a digital world. The translation to Long Distance Learning and Therapy sessions won’t be far behind
But the BIG question is what will our theory and therapy look like in the distant future????
In order to anticipate the role of psychodynamic and psychoanalytic therapy in 75 years from now we have to try to anticipate what will the state of the art of science, medicine and general psychiatry?? Let’s remember how far psychiatry, medicine and modern technology has come in the past 75 years
Although the effects of penicillin was discovered a few years earlier it wasn’t until 1939- 75 years ago that a usable product was developed which we would say was the first antibiotic
In 1938 76 years ago Cerletti and Bini introduced ECT therapy
75 years ago – it would be another 10 years until Lithium therapy for bipolar was discovered by John Cade
75 years ago it would be another 12 years before chlorpromazine the first antipsychotic medication would be introduced.
Forget about computers 75 years ago regular TV was just started in the US Bill Gates father was 14 years old and his mother was 10 years old
We know scientific advances occur exponentially – meaning that they will occur much faster in the next 75 years then they did the previous 75 years ago.
So what clues do we have what psychiatry will be like in 75 years from now? And what predictions can we make?
We will have a much more complete understanding of the genetic and biological nature of Major Depression, Schizophrenia, Bipolar Disorders, PTSD and Dementia as well as entire new sophisticated methods of treating them and preventing much of the symptoms manifestations. Just looking at the journals which come across my desk in one recent month I noted:
The role Apolipoprotein e-4 allele gene and depressive symptoms as well as the relationship to cognitive disorders
Psychosocial risk factors associated with elevated plasma peptide endothelium
Genetics predicators of lithium response
Relationship between heart disease and depression
Relationship between depression and diabetes
Role of inflammation and psychiatric symptoms
The Role of Transcranial Stimulation on Depressive Disorders
Neuroimaging differences in patients with Borderline Personality Disorder
You also may have seen a recent article the Academy Journal by Michael Stone which discussed Borderline personality related to hyper-reactivity of the Limbic System
I believe that it is fair to say that in 75 years from today, modern medicine will have extremely effective medications, injections of genetic material, brain stimulation , possibly even some type of surgery as well as techniques we have never heard of that will be effective in eliminating, controlling and preventing so much the psychiatric manifestations that we see today in our psychiatric practice. Treatment will be complicated and will require not only a understanding of the state of the art science and medicine but an understanding of human behavior and interactions. Therefore they will still be best treated by physicians who are especially trained in medicine as well as in human behavior and interaction by which I mean psychiatric specialists. Of course it is possible that some of these treatments will be relative simple and will not require specialists and many conditions may be treated by general medical physicians as they often are today.
However- No matter how effective these treatments are, they won’t be able to eliminate the effect of human interaction especially during child development on personality development, conflictual feelings such as love, hate, guilt, empathy, object choice, positive and negative identifications, competitiveness, passiveness, creativity adaptation, maladaptation, happiness and sadness, fulfillment and lack of fulfillment.
I believe that EVIDENCE BASED Research will continue to accumulate which will show that the state of the art intensive psychodynamic psychotherapy undertaken in adulthood will be the most effective therapeutic method to bring about an emotionally full filling life. It will become known and accepted that the previously mentioned biological based treatments although immensely successful in treating major depression, OCD, bipolar, PTSD, panic disorder, perhaps social phobia, hopefully Schizophrenia , hopefully various forms of autism WILL NOT be able to address the effects of human interaction, thoughts and fantasies on the developing personality nor on the ultimate satisfaction with self and relationships and with one’s place in the world BUT a meaningful modern psychodynamic therapy will do so.
I believe evidence based research will show that biological based treatments mentioned previously will be extremely effective in eliminating biological and genetic psychiatric conditions and may very well be able to mitigate the emotional response to relationship issues, the emotional response to loss self esteem, PTSD etc. but certainly will not prevent these situations, external and internal which cause anxiety and depression, from reoccurring. But I also believe that evidence based research will build on the existing body of knowledge that strongly suggests that meaningful intensive psychodynamic therapy – let us say for sake of discussion – about two years of psychodynamic treatment- will be the most effective for doing such and produce the best results for having the least debilitating symptoms and the opportunity for a more full filling life. In the past 10 years there has been an increasing amount of Evidence Based Research and discussion about the efficacy of Psychodynamic Therapy.
If science research shows this form of treatment is effective – People will want it and expect it! The questions remaining are who will do it, who will pay for it and how will it be different than the treatment we do today ??
WHO WILL DO IT?
Most likely the newer form of psychiatric treatment dealing with newer medications, genetic treatment, brain stimulation, other biological interventions yet to be conceived will be handled by physicians with special interest and training in human behavior – in other words, psychiatrists. As is often the case today- when psychotherapy is indicated the same doctor who is handling the biological forms of treatment if trained in psychotherapy is in the best position to do psychotherapy also . And that would be psychiatrists.
Recently I have been interviewing past presidents of the Academy and asking them about the pathway of their career. Many of them as have I, were drawn into this field by first being fascinated with the working of the brain and then ultimately finding that, as challenging as the interventions we could do as physicians- it was even more interesting and rewarding to interact with patients and help them make meaningful changes through psychodynamic therapy. I can see his happening in the future, as generations of medical students will gravitate towards psychiatry as tremendous advances are made in treating mental conditions BUT ultimately they will realize that in addition to these interventions, the ultimate intervention for many people will be a period of intensive psychodynamic therapy.
OF course as is the case now- the amount of people of wanting and needing psychodynamic psychotherapy will well exceed the number of psychiatrists available to perform this therapy. So there is every reason to believe that our colleagues in other mental health professions will continue to develop their skills in psychodynamic psychotherapy and will be performing this service as many of them are now.
But let us imagine for a moment that time and research has determined that even after all the latest bio-genetic, brain stimulating, psychopharm forms of treatment, it has been clearly shown that an intensive psychodynamic therapy makes a big difference in people’s lives…… WHO WILL PAY FOR IT?
In 75 years from now it seems clear that we will have some form universal health care program – maybe single payer or maybe more like the current health care that is being rolled out. IT most certainly will cover the biological, genetic, new medical brain stimulating, modern psychopharm treatment etc and if the scientific evidence is clear the people will demand and our universal health care could very well cover the 2 years of psychodynamic treatment I envision will be needed and wanted by so many people. BUT what if evidence is there to prove that it is worth the time and money but the future political climate won’t allow it……?
Are there any other possibilities other than the rich shell it out and it becomes a treatment for the elite? Remember we anticipate that median life span may very well be 100. People are going to living longer and be healthier longer. People will be working and living much longer than today.
Today, if we get a mortgage on our home it is for 20 or 30 years because people are expected to have that long of a productive working life. That also was the basis for college and post graduate loans. It is worth it, if people correctly believe that psychodynamic therapy in their 20s 30s or 40s will make a difference in the next 60 to 80 years of their lives, but intensive psychodynamic therapy is going to cost them over a two year period maybe 5-10 % what their mortgage might be worth, why not take a mortgage on their psychological well being? It could be attached to their mortgage which will will be 30 \or 40 year loans or have such loans institutionalized as education loans are these days especially since people may be living and working 10 or 15 years longer then anyway.
How will Psychodynamic therapy be different than it is today?
In order to anticipate this question , we would have to know how our lives will be different. How will childhood experiences be different? How will families be different ? How will technology impact our lives? What degree of poverty will IMPACT child development or lack of it . We are pretty sure that people are going to live longer and therefore people’s psychodynamics are going to be influenced by growing up in multigenerational families. There will be more great grandparents as well as grandparents interacting with the developing child . Perhaps more complicated patterns of competition and identification.
What will we learn about children being raised by LGBT parents ?
How will some of the assumptions and psychodynamic theory be changed and modified as we understand the kids developing in same sex families? Similarly, new understandings will emerge as in the future as we have large numbers of people who are test tube babies perhaps genetically altered.
I have observed and have written elsewhere on this blog about the tremendous drive of adopted, children or children raised by one biological parent to connect in some way with their both biological parents and their families whenever possible –even if adopted at birth or raised by one biological parent.
We just now beginning to see the emergence of children who are digital natives. – meaning they have been using digital devices since they their earliest memory – often starting at age 2 and 3 . How will this play out in 75 years after 3 or 4 generations of this child raising component with even newer technology? How will their object relations, socializing patterns etc be impacted by this this technology in their lives?
The latest statistics show that today 1/3 of people getting married have met online. So it is probably safe to assume in 2089 most serious relationships will be started online. Those of you who saw the movie HER realize that people are considering that it may be possible to establish a meaningful relationship with a so called person who is only a computerized program. Consider the psychodynamic implications of that!
As therapists we are always interested in the patients emotional reactions to their thoughts and fantasies, especially when they occur during a therapy session. This is also an important aspect of transference and countertransference. We also use our own emotional reactions to what is being discussed in therapy. We know also that emotional reactions are accompanied by physiological changes throughout the body including changes in activities in various parts of the brain. All of these emotional responses can occur before there is conscious awareness of the emotional reactions. I usually wear a fit bit on my wrist. This is wrist band which measures my heart rate and number of steps I take – it also recognizes when I am sleeping. This is a first generation device. Similar devices are being developed that measure BP, pulse respiration rate and future devices are expected to have the capacity to measure cortisol levels and even other hormones including sexual arousal etc. Perhaps a little band around the head would measure electrical activity of the brain. The capacity to wirelessly project any measurements to a computer screen or projection screen already exist. So I can imagine that if the patient and the therapist each wore these devices we would have the ability to measure all these internal manifestations– ALL which could be observed by the therapist or the patient or possibly both during the therapy session.
Obviously I really don’t know what is in store for our organization or the future of psychodynamic psychiatry and our profession. I do know that there is going to be lots of change. The tradition of our Academy has been one that respects the work done in the past but always has a willingness to consider new ideas. I hope we will continue to do this and that we will take steps to continually change our organization to meet the needs of our profession and embrace what is to come 75 years from now or 150 years after Freud AND BEYOND
Any comments are welcome below
The following is a an article published in the Spring 2014 edition of The Forum
The Search for a Person’s Biological Identity
By Michael Blumenfield, M.D.
Philomena-One of Several Films Defines The Issue
One of the top movies of 2013 is Philomena. This is the story of an elderly woman, (played magnificently by Judy Dench) who as teenager had an out of wedlock child at a convent. The movie has several interesting themes one of which is the incessant drive that a woman has to reconnect with a newborn child, which she gave up at birth. The film is based on a true story documented in a non-fiction book.
This is also a recurrent theme in several movies that I have reviewed (FilmRap.net). The Kids Are All Right, which starts Annette Benning, Julianne Moore and Mark Ruffalo, is about two lesbian parents who are raising two teenage kids who were conceived by artificial insemination with the use of a sperm donor. The film raises the possibility of what might happen if one of the children decides to track down his or her biological father. Obviously this could happen to a heterosexual couple and is an increasing possibility as new medical techniques are increasingly used to conceive and carry a pregnancy. One of the screenwriters for this film has indicated that the script was based in part on some aspects of her life.
The Movie People Like Us with Chris Pine, Elizabeth Banks and Michelle Pfeiffer is about a man who upon the death of his father discovers that he has a 30 year old sister who he never knew about. This changed his entire understanding of his family and his own identity. The screen writing team that wrote the story also indicated that they had first hand knowledge of these issues.
Stories We Tell is a documentary film by Sarah Polley. It is about the complicated journey she has gone through as she uncovers secrets about her own family especially finding out that the man she thought was her father was really not her father. Two other very good films that I have seen in recent years that have dealt with various aspects of these themes have been Admission and Mother and Child.
These movies highlight situations that occur more often than most people realize. In situations where the man is in a relatively stable marriage, or is single and doesn’t want to get married, but is promiscuous and fathers a child, he is faced with a decision. He could acknowledge the child’s reality but choose to stay with his current relationship, or leave his original family if he is married (presumably with a divorce) and establish a family with his new child. His wife, if he was married, could make this decision for him by deciding that she would not want to live with him any more. (The second woman might not want him either.) It is possible that the father may not even know that he has created a child, as the mother of the child may not wish to tell him. The pregnant woman, of course, has to make this decision, as well as the decision whether to have the child or get an abortion.
There are also situations where a couple has a child but don’t establish a relationship and the man moves on. He then has a family at a later date and does not tell them he has fathered a child in the past. Still other variations are possible such as when a single woman becomes pregnant and gives the child up for adoption and then goes on to live her life and perhaps ultimately have a marriage and children but never mention her past history.
I am sure there are other scenarios including twins separated at birth, siblings separated at early age and not having full awareness of the other, etc. Even before the discovery of the unknown family member is made, the parent who knows the secret has the burden of keeping the secret and not being able to be truthful with people to whom they are very close, usually a spouse and children. This can lead to guilt or fantasies of what happened to the secret child. The child who only knows that his or her biological parent has abandoned him or her can never know the reason why and may incorporate fantasies involving his or her self-worth or even grandiose thoughts about being rescued by the birth parent. A story told to the child that the missing parent died will of course backfire when and if the parent appears someday and all must deal with this major piece of deception no matter how well-intentioned.
Self-Identify Founded on Life history As We know It
Our ideas of self are founded on our life history as we know it, including early childhood experiences, memories, and fantasies that are influenced by all variations and the nuances of the major players who impacted our earlier life.
There are an unlimited number of circumstances that could lead to the discovery of the unknown family members. Once a previously unknown family member is identified, the child very often has a strong desire to know about the biological parent and also meet and relate to the siblings who usually would be half siblings, sharing one parent in common.
What is the meaning of having an awareness of the existence of a biological family member who has not influenced your life for many years? What makes connecting with that person so important? Is it because you share some genetic makeup in common or that you come from some common heritage that drives the need for establishing this relationship? Is there a need to fill a void of being alone and that can be corrected by meeting someone who shares some part of you? In the case of the newly connected siblings, is it the desire to rectify the mistake of the parent(s) who were not able to construct a complete family for all their children?
Three Case Examples
I would like to present three real cases (disguised) to illustrate some of these issues. I was not the therapist for any of these people so I do not have other information about the psychodynamics.
#1. A successful attorney was married for the first time at age 35 to a 28-year woman. They had three children and a fairly close-knit family and he never had any extramarital relationships. He died at age 65 and 10 years later a 45-year man contacted the now 67-year-old widow and told the following story. This man lived in another city with his mother and he had been told that his biological father was a successful attorney with whom she had a close relationship and who had subsequently died. (In reality he left her after she became pregnant and he moved to another city.) She told her son the unusual last name of his father. He found the name easily on the Internet since he was fairly well known in his field. He never told his mother that he had information about his biological father. After his mother died, and he himself was married with an 18 year old son, he located the widow of his biological father and told her who he was. He asked permission to visit her and wanted to meet her now grown and married children and any other close family members. She agreed. She had known about her husband’s previous relationship prior to their marriage (but not about this child) and asked her children if they wanted to meet him. The oldest son was not interested but the other two agreed. An older sister of the deceased husband was not interested but her grown son was agreeable.
The younger married middle-aged children of the deceased attorney established a good relationship with the “new family member” and they would visit each other when they happened to be traveling cross country to each other’s cities for other family events. Eventually the oldest son of the deceased father found that he had certain hobbies in common with his half-brother, e.g. sports car racing and golf, and he would join in these family occasions and he began to relate to his half brother. The grandson of the older sister of the deceased man was able to help the son of the new family member get a job in the entertainment business. He and all of deceased attorney’s sibs and the widow now consider him part of their extended family. When asked why he sought out his other family, he said he felt he owed it to his son to try to give him the extended family that he never had.
#2. The new young wife of a well known sports figure died in childbirth but their infant son survived. The father was devastated and gave his son up for adoption to a distant cousin with whom he did not have any subsequent contact. The boy was brought up two loving parents. When he was a teenager he was told the name of his famous biological father who supposedly had no interest in seeing him. When this child is a grown man of 50 years old, he was in a movie theater with his wife watching a documentary about his biological father who was a legendary sports icon.
At one point in the movie the former sports figure recounted that he felt bad that many years ago he had a son whom he never met after his wife died in childbirth and he wonders what happened to him. The grown son was stunned by the interest shown in him. He contacted the filmmaker and asked if he could contact the sports icon who now lived in another country. The filmmaker agreed to arrange an all-expense-paid reunion if he could film it. The father is now a grandfather as is the son, and, after an initial meeting, the two families subsequently kept in touch with and visited each other from time to time.
#3. A teenaged mother gave her out-of-wedlock daughter up for adoption. Her daughter was raised by two loving parents. When the daughter married and had children of her own, she decided to track down her biological mother. She hired a private detective who was able to find her mother who was living alone in another city and had no other children. The daughter made contact with her, introduced her to her family, visited periodically and brought her to various family events. The oldest granddaughter became particularly close to her.
These three cases are obviously the bare facts and should raise clinical questions about the psychodynamics that are at play. What is clear is the strong need on the part of at least one person to connect with a long lost biological relative and family. There appears also to be an acceptance and probably a strong need on the part of the other family member or members to accept this contact and to learn about the lost biological family member. I believe that this area is ripe for both survey research, case reports with clinical discussion of the theoretical implications and psychodynamic and psychoanalytic theory on this subject.
Proposed Research Study
I would like to propose a research study to start this off which one or more of the readers may wish to organize. This would be a survey of the members of this Academy with the following questions:
1. If today you were contacted by the hospital where you were born and told that you were accidentally given to the wrong family, would you want to contact and meet your biological parents and or their families?
2. Explain your reason. What would your need be if you agreed to do this and were there any conflicts in considering this question?
3. Would you feel differently if the parents who raised you were alive or deceased? Explain.
4. How would you feel if one of your children were notified as above and subsequently made contact and established a relationship with his or her biological family?
I would hope that the self awareness and insight of the Academy members would provide a good start into understanding the questions which I tried to raise in this article. If anyone is interested in organizing this study let me know and I will put you in touch with others who are interested so a collaborative study might be developed. I will step aside from this project but will eagerly follow any developments.
Dr. Blumenfield is President of the Academy of Psychoanalysis and Dynamic Psychiatry. He is The Sidney E. Frank Professor Emeritus of Psychiatry and Behavioral Sciences at New York Medical College. He currently lives and practices in Los Angeles where he writes a blog PsychiatryTalk.com and also reviews movies on a blog with his wife at FilmRap.net
In 2007 I interviewed Dr. Alfred M. Freedman who had been President of the American Psychiatric Association in 1973 when this event occurred. He described the details of how this resolution was passed by the APA Assembly . The interview was part of a video podcast series which I was doing at New York Medical College. It was subsequently transcribed in the Journal of Gay & Lesbian Mental Health Volume 13 Number 1 January -March 2009 pages 62-68. The interview is available on the Internet in 5 short segments. Segments 3-5 deal mostly with this issue. In view of the historical significance of this event. I have put links to this interview below:
Interview with Dr. Freedman – Segment #1 – 6 minutes 20 seconds http://www.youtube.com/watch?v=jhiyDAprlP4
Interview with Dr. Freedman – Segment #2 – 9 minutes 58 seconds http://www.youtube.com/watch?v=smvDA_9GJyE
Interview with Dr. Freedman – Segment #3 – 8 minutes 41 seconds http://www.youtube.com/watch?v=bmtr5kmpBus
Interview with Dr. Freedman – Segment #4 – 7 minutes 59 seconds http://www.youtube.com/watch?v=zLREZflrQrA
Interview with Dr. Freedman – Segment #5 – 4 minutes 24 seconds http://www.youtube.com/watch?v=z5YsWT48lEE
For more information about Dr. Freedman see an earlier blog .
Michael Blumenfield, M.D.
5 Days at Memorial: Life and Death in a Storm Ravaged Hospital by Sheri Fink – This is a great book for anyone who works in a hospital especially doctors and nurses who realize they could be on call when a disaster might strike. Also include yourself in this group if you are a hospital administrator or someone who likes to wrestle with ethical dilemmas. Be prepared for a lot of repetition, medical details that may all seem to be almost the same to most people as well as for some dips into the history of this hospital, other disasters and a course in ethics over the years even dating back to ancient times. If you can handle all of this, you really have an exciting, intellectually stimulating book with a look at disaster medicine, making medical and ethical decisions under difficult circumstances and some good legal battles. The main event was the 2005 Hurricane Katrina, which was the costliest natural disaster, as well as one of the five deadliest hurricanes in the history of the United States. At least 1,833 people died in the hurricane and subsequent floods. This book deals with the impact of the storm on Memorial Hospital in New Orleans, which was a 312-bed hospital, which included patients receiving intensive care and a larger section of the hospital where critically ill patients were treated. As the floodwater rose, most of the power in the hospital was irretrievably lost. There was no sanitation, and they were running out of food. Indoor temperatures were as high as 110 F degrees. At one point there were over 2000 people in the hospital as the numbers swelled with families of patients and staff as well as refugees from the surrounding city. The hospital became surrounded by water and there was no way to leave by car. A makeshift helipad was established on the roof but to get there patients, had to be carried up several flights of stairs usually in the dark and passed through a hole in the wall to get to another part of the hospital complex and up additional stairs. There was limited oxygen for these patients and for some the nurses had to squeeze a balloon like device to get the air into their lungs and drip an IV into their veins while going up the stairs. It was difficult getting enough helicopters to remove all the people from the hospital. Decisions had to be made which patients to evacuate first. Should it be the ones that were barely alive and wouldn’t be expected to even survive the trip to another location or perhaps already had a fatal illness where their demise was expected in a few days or should the patients go first who had a better long term outlook but still required hospital care?? Should the preference or order of care be influenced if the patient had a DNR order, meaning do not resuscitate the patient if their heart stops or if they stop breathing. As the first three or four days passed most of the people were evacuated (where they were evacuated to was another problem). There was confusion and questions about the actions by the corporation that owned the hospital and what arrangements they were making to help the stranded hospital’s need for evacuation. Outside the hospital gunshots were heard and there were concerns that looters might enter the hospital by boat. There was a concern about the physical integrity of the old hospital walls. You would think that the National Guard and the US Government should have done a heroic operation to save everyone from the beginning. They apparently were saving people from rooftops of their homes, helping out in the Superdome, which was the place of last resort for the people of New Orleans who weren’t able to escape before the flood, as well as sporadically appearing on the helicopter pad. In the end there were a small number of doctors and nurses trying to care for the remaining and sickest patients. There was concern that even moving some of them would be fatal. One man was so obese that they couldn’t figure out how to move him. Some patients were clearly in the last hours hours of their lives. Others would soon be that way if they didn’t get more intensive care. One of the remaining doctors along with two nurses was Dr. Anna Pous, a very compassionate and brilliant ENT surgeon who had a history of reconstructing patients with advanced cancer. She found herself faced with the task of trying to relieve the suffering of several remaining patients. It is well known to physicians and nurses who treat dying patients, that morphine often in combination with a rapid acting tranquillizer such as Versed, given intravenously will relieve the pain and agonizing difficulty breathing in the final stages of life. It is also known that this treatment could hasten their demise. Dr. Pous appeared to made the decision to have several patients receive large doses of morphine and Versed which would peacefully end their lives. At a later point in time this was felt by some people to be murder. In fact, Dr. Pous was actually arrested, handcuffed and was with two nurses charged with second-degree murder. The response of the medical community from this hospital and from across the country, the legal and emotional reactions of some of the patient’s families, the media hype and the ethical questions which were being asked, were an important part of this book. The book provides few answers and lots of stimulating questions. The author won a Pulitzer Prize for her reporting on this subject in the New York Times Magazine. If you are drawn to this subject you will not be disappointed.